Preliminary data from a current NCNR funded study reveal that a comprehensive discharge planning protocol developed specifically for the elderly and implemented by gerontological nurse specialists is decreasing the total number of hospital readmissions and increasing the time between initial hospitalization and rehospitalization for subjects in the experimental group. The rehospitalizations of elderly account for at least one-quarter of all hospital admissions; even a small decrease in hospital readmission rates could achieve substantial savings for the Medicare program and improve the quality of elders' lives. The proposed randomized clinical trial will build upon the current study by adding a home care component implemented by nurse specialists, targeting the clinical intervention at high risk elderly, measuring its effectiveness at a large teaching and a smaller community hospital and examining the nurse specialists' interventions. The purpose of this study is to compare patient outcomes, caregiver outcomes and cost of care between 2 groups of high risk elderly patients and their caregivers: a control group (180) that will receive the hospitals' general discharge plans and, if referred, the home care agencies' routine procedures; and an experimental group (180) that will receive a comprehensive discharge planning and home care protocol implemented by nurse specialists via hospital and home visits and telephone contact. Both the control and experimental groups will include hospitalized elderly from 6 DRG categories (3 medical and 3 surgical). The study will examine: 1) patient outcomes-functional status, mental status, physical symptoms, depression, subjective health rating, self-esteem, post-discharge infection and rehospitalization rates, satisfaction with care; 2) caregiver outcomes-physical symptoms, use of health services, depression, subjective health rating, self-esteem, social support, competence, strain, satisfaction with care; and 3) cost of care-rehospitalization, post-discharge health services, patient out-of-pocket costs, nurse specialist services. Both groups will be followed for 6 months post- hospital discharge. Data analysis will include MANOVA, chi-square and t- tests. Study outcomes will provide important data on: the effects of discharge planning and home follow-up by nurse specialists for high risk elderly and their caregivers; the relative cost of this intervention; and the major interventions needed in meeting the discharge planning and home care needs of high risk elderly and their caregivers. Data will be of significant use to researchers, providers, insurers and policy makers.